Distal Biceps tendon Repair
Distal biceps tendon rupture is commonly reported in males with reliable outcomes and minimal long-term complications. It is not encountered too often in women. In male patients, the distal biceps injury is often associated with an acute traumatic event with acute pain, swelling, ecchymosis, weakness in flexion of elbow and supination of the forearm. The patient may exhibit signs of chronic tendinosis following chronic tearing of the tendon. Surgical treatment is always suggested in order to restore the supination and the flexion strength.
The biceps muscle of the arm is located in front of the upper arm. Its function is to help in bending the elbow as well as providing rotational movements to the forearm. It also helps in maintaining stability in the shoulder joint. The biceps muscle has three tendons: Two that attaches to the bone of the shoulder (scapula) and one that attaches at the elbow (radius). At the elbow, this is the distal biceps tendon which is responsible of the flexion at the elbow and the supination of the forearm allowing the motion of palm up of the forearm/hand. The palm-down motion is done by the pronator muscle. If the distal tendon tears and detaches from the bone, it can’t regrow but should be repaired surgically.
In women the incidence is not well understood. There is only a limited number of cases reported and the presentation of the symptoms differ from the men because these lesions are seen in older women. In men the risk factors include smoking, corticoid and anabolic steroids use. Tears are seen after an unexpected extension force and typically a “pop” is felt at the distal aspect of the arm. Diagnostic and determination of plan of care will decide if surgical treatment is mandatory. Women and younger men have often partial tears that may not require surgical treatment. Rarely the tear can involve also the proximal aspect of the tendons at the shoulder.
Once the muscle tears distally, the bulk of the biceps may disappear and the biceps muscle foreshortens and bulges out forming the deformity called “Popeye’s” deformity reminding the cartoon’s personage. Such injuries are consequent to a sport activity in which a forceful and eccentric contraction of the biceps muscle occur during an activity like lifting.
An acute rupture of the distal biceps tendon can be treated with acceptable results because the most you may lose in elbow flexion strength may reach 30% of power while up to a 50% of supination strength of the forearm can be affected. It is mainly the reason why such injury is better repaired surgically, especially if we are dealing with a dominant upper extremity.
The biceps muscle is located in front of the upper arm and attaches to bones of the shoulder and the elbow by tendinous portions. A tear of the tendon at the elbow is uncommon and is seen only on 3 to 5 people in 100,000 per year. It is even rarer in women. Often, the tears are caused by a sudden injury resulting in a weakness in flexion at the elbow and the supination of the forearm. Only a surgical treatment may return the extremity to a near normal strength.
The biceps bend and rotate the arm. It flexes the elbow and supinate the forearm because of the attachment to the greater tuberosity of the radius. The tears can be partial or complete. A complete tear of the distal tendons is seen when the tendon has pulled away from the radial tuberosity. Even when such injury is seen, a reasonable function of the extremity is expected because other muscles will compensate and offer a reasonable function to the extremity with the deficit, we described already of 30% loss in flexion and up to 50% loss in supination of the forearm.
Injuries to the biceps tendon at the elbow is often seen when the elbow is forced against resistance especially when one is lifting heavy loads. It is less commonly injured when the elbow is bent during the action. Injuries are seen when the elbow is kept in extension, presenting a stronger resistance. Men older than 30 are seen with such injury while performing in heavy loads work.
Studies have shown a relation between Smoking and distal biceps tendon tears, likewise Nicotine may impact on the quality and the strength of the tendon. Medication like corticosteroids, anabolic steroid medications have been linked to the degeneration of the tendon and perhaps weakening the tendon.
A distal tear may show a retraction of the tendon and the biceps muscle balling up with typical bleeding or bruising in the soft tissue as seen in the above photograph. There is always a history of a “popping” sensation at the elbow with minimal pain or discomfort. Swelling can be noted at the elbow with a palpable gap at the distal portion of the biceps muscle. In a young worker, especially if the dominant upper extremity is involved, surgical exploration and repair will provide the best result although it is impossible to guaranty a full return to power.
An anatomical fixation of the biceps tendon (Repair) to the radial tuberosity is always recommended with different approach techniques for the fixation. Complications are common and remain directly related to the surgical approach. Radial sensory neuritis, lateral antebrachial cutaneous neuritis (LABC), Heterotopic bone formation (HO), Infection, re-rupture of the repaired tendon, posterior interosseous nerve palsy (PIN), radio-ulnar synostosis, complex regional pain syndrome, brachial artery laceration and decrease in range of motion (ROM).
The best way to repair such injury is to re-attach the biceps tendon to its point of insertion at the tuberosity of the radius. This procedure is better done in the two to three weeks after the injury. Many techniques are suggested using a bone tunnel with suture anchors or suture buttons. Generally, a two-incisions technique is recommended to avoid any complication to the nerves (radial, lateral antebrachial or posterior interosseous nerves).
Similarly, the long head of the biceps, proximally can also rupture and be addressed by two ways in performing a tenodesis and in re-attaching the long head to the proximal humerus from its original position at the glenoid. It can be re-attached by screw or suture anchor to the proximal humerus shaft. Many may perform a simple hole in the proximal humerus and anchor the proximal tendon to the bone. A simple tenotomy can also be done by releasing completely the long head of the biceps from its origin, allowing it to retract into the bulk of the muscle belly.
A degeneration of this tendon is frequent causing a rupture of the tendon. Often a retraction is seen especially in an arthritic shoulder. It is rarely a traumatic event. It may be good also to mention that proximal rupture of biceps tendon although not the topic of the discussion in this paper, can be fixed by open procedures and as well by arthroscopic techniques.
Depending on the severity of the injury, the muscle may heal over time without any corrective surgical treatment. Compresses warm or cold as well as anti-inflammatory medications will ease the pain and reduce swelling. More severe injuries will require surgical treatment and additional physical therapy treatment to regain strength and functionality. We have a tendency in keeping such surgical options to elite athletes while we will offer a conservative treatment to the older patients.
Imaging studies can supplement the clinical flair. X-rays have a little place in helping with the diagnosis but it can be useful to detect an avulsion fracture associated to the greater tuberosity of the radius.
Ultrasound study can show the distal tendon especially when it has retracted or coiled up in the arm. MRI can also help in the diagnosis in showing the rupture of the distal end of the tendon.
The only way you may return to a full strength and range of motion is to re-attach the distal end of the tendon to the radial tuberosity. A conservative treatment can be offered as well… especially when we are dealing with a non-dominant upper extremity. People with medical problem and also the one unable to attend physical therapy, can be exceptions for a surgical treatment but anti-inflammatory medication, rest followed by a rehabilitation program will be required.
After a lapse of 2-3 weeks after the injury, swelling should be down and a transverse or a longitudinal incision can be performed on the anterior surface of the elbow. The torn tendon will have the tendency in scaring down or shortening. The goal of the surgical treatment is to re-attach the distal aspect of the tendon to the radial tuberosity with stiches or anchors.
Some of us prefer a two-incision technique to avoid injury to the nerves (one in front of the elbow and another one posteriorly). The tendon may become too short to be re-attached to its origin, then it may become necessary to supplement it with a graft. I generally like to use the Fascia Lata of the patient (autograft) or a synthetic material (allograft) which will allow the lengthening of the structure.
A bone tunnel can be also performed at the level of the greater tuberosity of the radius or the use of an anchor stich allowing the tendon graft to pass through or be trans-fixed securely to the bone. This is the best way to re-attach the distal Biceps tendon to its origin under a good tension allowing pronation and supination of the forearm as well as flexion of the elbow. Other sources of grafting can be found in the body using a fascia or even a synthetic graft (allograft) as described above.
The procedure is an out-patient procedure and a long posterior splint or a brace at near 90 degrees limiting a full extension is applied for comfort and protection of the surgical repair for two to three weeks with an arm sling. A small amount of pain medication for comfort and Vitamin C, go to my routine when taking care of such injury.
A follow-up visit will remove stiches if needed and a physical therapy program will start around the third week of the post operative period actively and then passively. Such patients should have modifications in their work load avoiding lifting above 20 pounds for a lifetime to avoid re-rupture.
Maxime Coles MD